1. Does the
production involve any of the following: pornographic
materials, ride alongs, hidden cameras, pranks and consumer voting?

Yes
No

2. Will you be
using a clearance attorney with at lease 5 years of relevant media
law experience?

Yes
No

Applicant Details

Operations:

Description of Operations:

Number of
Employees:

Insurance History

1. Any insurance
declined, cancelled or non-renewed that provided the same or similar
coverage s the insurance sought?

Yes
No

If Yes, please provide explain. Not applicable in MO.

2. Any prior E&O coverage?:

Yes
No

If Yes, please provide Policy Type, Carrier,

Policy #, Expiration and Premium above.

3. Any
loss in the past 3 years?:

Yes
No

If Yes, please provide Policy Type, Carrier,

Policy #, Expiration and Premium above.

Representations

1. Are You aware
of any claims or legal proceedings made or commenced against You or any
of Your officers, members, or partners within the last five (5) years
for: (1) invasion of privacy or false light; (2) IP Infringement; (3)
defamation; or (4) breach of contract arising out of the alleged
submission of any ideas, story line, or script?

Yes
No

If Yes, provide
Policy Type, Date of

Loss, Description and Amount
above.

2.
Are You aware of any claim or threatened claim made against You or
any of Your officers, members, or partners arising out of or related
to the insurance sought, including title thereof?

Yes
No

If Yes, provide
Policy Type, Date of

Loss, Description and Amount
above.

3.
Applicant agrees to obtain from third parties from whom it will
obtain services or content for the insurance sought written
warranties and indemnification against claims arising out of the use
of such services or content?

I Agree
I Disagree

4.
Applicant agrees to use its best
efforts to determine whether any content to be used in the named
production or production library is protected by law and, and where
necessary, to obtain from parties owning rights therein the right to
use the same in connection with the insurance sought.

I Agree
I Disagree

5.
Applicant agrees to use its best
efforts to utilize clearance procedures which are the same or
similar to those attached to this application.

I Agree
I Disagree

Clearance, Licenses, Consents,
and Releases

1. Has a title search for the Named
Production been conducted by a title clearance service?

Yes
No

2. Is the name or likeness of any actual living person used, portrayed
or identifiable in the Named Production?

Yes
No

If Yes, please explain above.

3. Is the name or likeness of any actual deceased person used, portrayed
or identifiable in the Named Production?

Yes
No

If Yes, please explain above.

4. Have all performers who appear in the Named Production entered into
a written performance agreement with the applicant related to their
appearance?

Yes
No

5. Has the Applicant obtained a license, consent or release from those
persons, animals or characters who appear in the Named Production
without a written performance agreement?

Yes
No

6.
In the past three (3) years, have You been given notice of any
potential infringement another party's intellectual property (IP)
rights, including without limitation, copyright or trademark
infringement?

Yes
No

If Yes, please explain above.

7. Did You screen the Named Production for the following possible
offenses?

None

Trademark
Infringement

Copyright
Infringement

False
Light Claim

Defamation

Privacy
Violations

Violation
of Rights of Publicity

Check All That Apply

8. If any of the
aforementioned screenings were performed, were such screenings
performed by, or under the supervision of, a qualified attorney?

The Additional Insureds is used to capture the distributors,
broadcasters, investors, talent and other entities required to be named
as additional insured under the policy. Certificates of insurance can be
issued for the additional interests scheduled. Please note that the
policy holder should not be scheduled as an additional interest.

Coverage Options

Effective Date / Policy Term:

/

Limits:

Per Claim / Aggregate

Retention:

Rights Period Endorsement:

For policies on
a claims made basis, the rights period extends the claims
reporting period to 7 years from the policy effective date.

Title Coverage:

Title coverage may be included if a title search
report is provided and approved by the insurance company.

Coverage Basis:

Claims
Made

Merchandising:

Merchandising provides coverage for
the marketing of the media content during the policy period.

By
clicking 'Submit Application' you are not
agreeing to purchase coverage. Via email, you will
receive a free, no-obligation insurance quotation.

Any person who knowingly and with intent
to defraud any insurance company or another person files an
application for insurance containing any materially false
information, or conceals for the purpose of misleading information
concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime and subjects the person to criminal and (NY:
substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK,
OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be
denied.

Please note
that once coverage is bound, the policy cannot be cancelled.

The insurance
quotation will be based solely on the coverages and limits selected
on this application.